Disorders of Sexual Function In a small number of couples (less than 1%), disorders of sexual function are the only reasons for the infertility. Disorders of sexual function include: failure of sexual intercourse because of inadequate penile erections (erectile dysfunction, impotence), failure of ejaculation, retrograde ejaculation and low frequency or mistiming of intercourse. With retrograde ejaculation, the tube between the bladder and penis does not close during ejaculation so that semen passes into the bladder instead of out via the urethra. Occasionally these conditions respond to treatment, but most often they do not. However if adequate sperm can be obtained by masturbation, nocturnal emission, vibroejaculation or electroejaculation, artificial insemination of the woman may be successful in producing a pregnancy. If the semen quality is reduced ICSI may be a more efficient method of treatment
Failure of Ejaculation
Failure of ejaculation is usual with chronic spinal cord injury and may also be caused by antihypertensive and psychotropic drugs but otherwise is an infrequent cause of infertility in most societies. Healthy men who cannot ejaculate with intercourse may be able to produce semen by masturbation, with a vibrator, or other stimulation.
Retrograde ejaculation occurs when the bladder neck fails to contract at the time of ejaculation so that all or most of the semen passes into the bladder. Usually, there is an obvious cause: prostatic surgery, diabetic neuropathy, pelvic nerve damage, or spinal cord injury. Retrograde ejaculation is diagnosed by the finding of sperm in urine passed after ejaculation.
An optimistic prognosis can be given provided that live sperm can be obtained. The couple is advised about the various techniques that might be used for collecting the sperm for artificial insemination or other Fertility treatments. The woman’s potential fertility must be evaluated.
Use of Collected Semen
If semen can be obtained by masturbation or by wearing nontoxic condoms to collect nocturnal emissions, the couple can be taught to inseminate samples at home. The timing of ovulation can be determined by calendar and either symptoms of ovulation or luteinizing hormone surge detected with a urinary luteinizing hormone dipstick kit. Freezing of samples for insemination or ICSI may also be possible.
Ejaculation may be stimulated by applying a vibrator to the underside of the penis near the frenulum of the glans. Vibrators with a 2-mm pitch and frequency of 60 Hz or more are most effective. Men with complete spinal cord injuries below T10 are unlikely to respond and will require electroejaculation. Modern electroejaculation equipment is safe.
If the semen quality is too poor for insemination or the risks associated with electroejaculation are considered unacceptable, aspiration of sperm from the testis and ICSI produces good results.
Retrieval of Sperm with Retrograde Ejaculation
Motile sperm may be obtained from the urine after retrograde ejaculation. Urinary pH is adjusted to above 7 and osmolality to between 200 and 400 mOsm/kg by administration of 80 g of sodium bicarbonate and 2.0 to 2.5 L of water daily for 3 days before the expected time of ovulation. On the day of ovulation, the man ejaculates and passes urine. Sperm are recovered from the urine by centrifugation, washed, and resuspended in an IVF culture medium. The final pellet is resuspended in approximately 0.5 mL of culture medium for insemination. It is also possible to cryopreserve the sample obtained. If this method fails, electroejaculation and catheterization of the bladder could be considered.